Provider Demographics
NPI:1962617845
Name:SMITH, EDWARD LAWRENCE (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LAWRENCE
Last Name:SMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-457-2100
Mailing Address - Fax:
Practice Address - Street 1:1411 N TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3043
Practice Address - Country:US
Practice Address - Phone:616-735-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016859207YX0905X
WI55826-21207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery